Bronchiolitis

Summary

This podcast episode from SketchyMedical dives into bronchiolitis, a common winter illness in children under two, often caused by respiratory syncytial virus (RSV). It presents with upper respiratory symptoms followed by lower respiratory distress. The episode humorously explores the condition's pathophysiology, diagnosis, and management, emphasizing supportive care over unnecessary treatments. It also discusses risk factors for severe disease, hospitalization criteria, and potential complications, providing a comprehensive review for medical professionals and students.

Takeaways

• 🌟 Bronchiolitis is a common winter illness in children, particularly affecting those under two years old and being the leading cause of hospitalization in infants and young children in the USA.
• 😷 The illness is characterized by initial upper respiratory symptoms like rhinorrhea and nasal congestion, followed by a lower respiratory inflammatory process.
• 🦠 The most common cause of bronchiolitis is the respiratory syncytial virus (RSV), which is responsible for about 80% of cases, with other viruses like rhinovirus, parainfluenza, and coronavirus also being possible causes.
• 🌡️ Clinical features of bronchiolitis are consistent regardless of the causative virus, but RSV and co-infections tend to result in more severe disease.
• 🍂 The physiological changes in bronchiolitis include airway edema, increased mucus production, and epithelial cell damage, all leading to lower airway obstruction.
• 👶 High-risk groups for severe bronchiolitis include infants under six months, especially those under three months, with additional risk factors being prematurity, chronic lung disease, congenital heart disease, daycare attendance, school-aged siblings, secondhand smoke exposure, and lack of breastfeeding.
• 🚫 Bronchiolitis is a clinical diagnosis, and routine lab work or imaging is not indicated for most cases. The American Academy of Pediatrics (AAP) advises against imaging due to the lack of correlation with clinical severity.
• 🛑 Treatment for bronchiolitis is primarily supportive, with no routine use of medications such as bronchodilators, racemic epinephrine, inhaled or oral glucocorticoids, leukotriene inhibitors, or antibiotics.
• 🏥 Hospitalization may be necessary for severe cases, indicated by dehydration, respiratory distress, apnea, lethargy, poor oxygenation, and a toxic appearance.
• 👨‍⚕️ Management of bronchiolitis in hospitalized patients includes supportive care with potential treatments like nebulized hypertonic saline, oxygen support, and in severe cases, intubation and mechanical ventilation.

Q & A

What is bronchiolitis?

Bronchiolitis is a common winter illness in children, particularly affecting those under two years of age. It is characterized by an initial upper respiratory infection that progresses to a lower respiratory inflammatory process, often caused by a viral infection.

Why is bronchiolitis particularly frustrating for pediatricians and parents?

Bronchiolitis can be frustrating due to its commonality and the fact that it primarily affects infants and young children, leading to significant distress for both the child and caregivers. Additionally, it often occurs during the winter months, which can compound the challenges of managing the illness.

What is the most common cause of bronchiolitis?

The most common cause of bronchiolitis is the respiratory syncytial virus (RSV), which is responsible for about 80% of cases.

What are some other viruses that can cause bronchiolitis?

Other possible viral causes of bronchiolitis include rhinovirus, parainfluenza, metapneumovirus, influenza, adenovirus, and coronavirus (not specifically COVID-19).

Why is bronchiolitis the number one reason for hospitalization among infants and young children in the USA?

Bronchiolitis is the leading cause of hospitalization in this age group because it can cause severe respiratory symptoms that require medical intervention, especially in infants and young children who have not yet fully developed their respiratory systems.

What physiological changes occur in the airways during bronchiolitis?

During bronchiolitis, the viral infection leads to lower respiratory airway edema, increased mucus production, and eventually sloughing and necrosis of epithelial cells within the airway, which results in obstruction of the lower airway.

What is the typical disease course of bronchiolitis?

The disease course of bronchiolitis typically begins with upper respiratory symptoms like rhinorrhea and nasal congestion, followed by the onset of lower respiratory symptoms such as cough, trouble breathing, and wheezing or crackles two to three days later. These symptoms generally peak in severity around days three to five.

Which age group is most affected by bronchiolitis?

Bronchiolitis usually affects children who are two years of age and younger, with those under six months of age, especially those under three months, at risk for more severe illness.

What are some risk factors for more severe bronchiolitis?

Risk factors for more severe bronchiolitis include age under 12 weeks, a history of prematurity, chronic lung disease, significant congenital heart disease, daycare attendance, school-aged siblings, secondhand smoke exposure at home, and lack of breastfeeding in early infancy.

How is bronchiolitis diagnosed?

Bronchiolitis is a clinical diagnosis based on a consistent history and physical exam findings. Lab work and imaging studies are not routinely indicated, but can be considered in special circumstances like severe illness or an unusual illness course.

What is the mainstay of treatment for bronchiolitis?

The mainstay of treatment for bronchiolitis is supportive care. There is no indication for the use of medications such as bronchodilators, racemic epinephrine, inhaled or oral glucocorticoids, leukotriene inhibitors, or antibiotics, as they have not been shown to have benefit and can cause adverse effects.

What are some potential complications of bronchiolitis?

Potential complications of bronchiolitis include aspiration pneumonia, respiratory failure, and the development of reactive airway disease, recurrent wheezing, or asthma, particularly in patients with severe disease or underlying conditions.

What preventive measures can be taken to reduce the severity of bronchiolitis and its spread?

Preventive measures include smoking cessation, good hand hygiene, breastfeeding, and RSV immunoprophylaxis with palivizumab for a small subset of high-risk patients under one year of age with specific conditions.

Outlines

00:00

🌲 Introduction to Bronchiolitis and Its Impact

The podcast from SketchyMedical begins with an introduction to bronchiolitis, a common winter illness in children that is both prevalent and frustrating for pediatricians and parents. The episode aims to review material to reinforce learning through videos, quizzes, and the Symbol Explorer. It invites listeners to watch the accompanying video for a visual aid. Bronchiolitis is depicted as an inflamed condition of the bronchial trees with red fruits symbolizing the infection, primarily caused by the respiratory syncytial virus (RSV) in about 80% of cases. Other potential viruses include rhinovirus, parainfluenza, metapneumovirus, influenza, adenovirus, and the regular coronavirus. The condition is characterized by initial upper respiratory symptoms that progress to a lower respiratory inflammatory process, leading to obstruction of the lower airways.

05:02

👶 Clinical Features and Diagnosis of Bronchiolitis

This section delves into the clinical features of bronchiolitis, which are consistent regardless of the causative virus. It highlights the disease's typical progression from upper respiratory symptoms like rhinorrhea and nasal congestion to lower respiratory symptoms such as cough, trouble breathing, and wheezing. Bronchiolitis is the leading cause of hospitalization among infants and young children in the USA. The physical examination includes checking for fever, respiratory distress, signs of dehydration, and lung sounds that may indicate bronchiolitis. Risk factors for more severe disease include age under 12 weeks, prematurity, chronic lung disease, congenital heart disease, daycare attendance, school-aged siblings, secondhand smoke exposure, and lack of breastfeeding. The diagnosis is clinical, and lab work or imaging is not usually required unless there are complications or severe symptoms.

10:02

🏥 Management and Treatment of Bronchiolitis

The management of bronchiolitis is primarily supportive, with most cases being self-limited infections. The American Academy of Pediatrics (AAP) guidelines recommend against the routine use of bronchodilators, racemic epinephrine, inhaled or oral glucocorticoids, leukotriene inhibitors, antibiotics, and chest physiotherapy, as they have not been shown to benefit patients and may increase costs and adverse effects. Hospitalization is considered based on the severity of the illness, with indications including dehydration, respiratory distress, apnea, lethargy, a toxic appearance, and low oxygen saturation. Inpatient treatment may involve nasal suction, nebulized hypertonic saline, oxygen supplementation, and in severe cases, intubation and mechanical ventilation.

15:03

🍼 Supportive Care and Prevention Strategies

Supportive care for bronchiolitis includes monitoring hydration, respiratory status, and oxygenation. Nasal suction and small frequent feeds are recommended for outpatient care, while hospitalized patients may require enteric or intravenous fluids, frequent suctioning, and oxygen support. Contact precautions are necessary to prevent the spread of the viral infection. Preventive measures such as smoking cessation, good hand hygiene, and breastfeeding can help reduce the severity of symptoms and the spread of infection. RSV immunoprophylaxis with palivizumab is recommended for a small subset of high-risk patients under one year of age with specific conditions like prematurity, bronchopulmonary dysplasia, or significant cardiac disease.

20:04

🚑 Potential Complications and Long-Term Outcomes

Complications of bronchiolitis include aspiration pneumonia and respiratory failure, with infants under six months and those with comorbidities at higher risk. Long-term, bronchiolitis can lead to the development of reactive airway disease, recurrent wheezing, or asthma, particularly in patients who had severe bronchiolitis, were younger than six months, or had a family history of atopy. It is important for caregivers to be aware of these potential outcomes and to consult with a pediatrician if the child exhibits wheezing with future illnesses.

25:06

👋 Conclusion and Additional Resources

The episode concludes by summarizing the key points about bronchiolitis: it is a self-limited viral illness affecting children under two years old, most commonly caused by RSV. It is characterized by fever, upper respiratory symptoms, and worsening lower respiratory symptoms around days three through five. The physical exam shows signs of increased work of breathing and abnormal lung sounds. Treatment is supportive, and there are specific recommendations against certain medications and therapies. Risk factors for severe disease and indications for hospitalization are outlined. The episode also mentions potential complications and the importance of prevention and risk reduction strategies. Listeners are directed to SketchyMedical's YouTube channel and website for more topics and resources.

Keywords

💡Bronchiolitis

Bronchiolitis is an inflammation of the bronchioles, which are the small airways in the lungs. It is a common lower respiratory infection in young children, particularly those under the age of two. In the video, bronchiolitis is depicted as a viral process characterized by initial upper respiratory symptoms like rhinorrhea and nasal congestion, which progress to a lower respiratory inflammatory process. The condition is most commonly caused by the respiratory syncytial virus (RSV), and it is the leading cause of hospitalization among infants and young children in the USA.

💡Respiratory Syncytial Virus (RSV)

Respiratory Syncytial Virus (RSV) is a common virus that causes bronchiolitis and pneumonia in young children. It is the most frequent cause of bronchiolitis, seen in about 80% of patients. In the video, RSV is personified by 'Gasper the Friendly Ghost' chilling next to an RSV tombstone, serving as a mascot to help viewers remember this key causative agent.

💡Viral Infection

A viral infection occurs when a virus enters the body and replicates, causing illness. In the context of the video, bronchiolitis is a viral infection that primarily affects the lower airways. The video mentions other possible viral causes of bronchiolitis, such as rhinovirus, parainfluenza, metapneumovirus, influenza, adenovirus, and coronavirus, emphasizing that the clinical features are the same regardless of the causative virus.

💡Pathophysiology

Pathophysiology refers to the biological processes underlying a disease. In the video, the pathophysiology of bronchiolitis is described as involving viral-induced lower airway edema, increased mucus production, and necrosis and sloughing of airway epithelial cells, which lead to obstruction of the lower airway. This is likened to the image of icicles dripping fluid off bronchial tree branches and the accumulation of sap, illustrating the obstruction.

💡Hospitalization

Hospitalization refers to the admission of a patient into a hospital for medical care. The video explains that bronchiolitis is the number one reason for hospitalization among infants and young children in the USA. It outlines the indications for hospitalization, such as dehydration, respiratory distress, apnea, lethargy, and low oxygen saturation.

💡Supportive Care

Supportive care in medicine involves providing treatments aimed at relieving symptoms and supporting the body's natural ability to heal. The video emphasizes that the mainstay of treatment for bronchiolitis, whether hospitalized or at home, is supportive care. This includes measures like nasal saline drops and suction, small frequent feeds, monitoring respiratory status and hydration, and avoiding unnecessary medications.

💡Dehydration

Dehydration occurs when the body loses more fluids than it takes in, leading to an imbalance in electrolytes. In the context of bronchiolitis, the video mentions that patients are at an increased risk for dehydration due to increased respiratory effort and decreased oral intake. Signs of dehydration, such as dry mucous membranes and delayed capillary refill, are important to monitor.

💡Respiratory Distress

Respiratory distress is a serious condition characterized by difficulty in breathing. The video describes signs of respiratory distress in bronchiolitis patients, such as nasal flaring, grunting, accessory muscle use, and tachypnea. These signs indicate increased work of breathing and may be a reason for hospitalization.

💡Oxygenation

Oxygenation refers to the process of oxygen being transferred from the air into the blood. The video discusses the importance of monitoring oxygenation status in patients with bronchiolitis. It mentions that supplemental oxygen may be indicated if a patient's oxygen saturation drops below 90, and can be administered via various methods such as nasal cannula or CPAP.

💡RSV Prophylaxis

RSV prophylaxis refers to preventive measures taken to protect against RSV infection. In the video, it is mentioned that RSV immunoprophylaxis with palivizumab (Synagis) is recommended for a small subset of high-risk patients under one year of age, such as preemies born at less than 29 weeks gestation and infants with bronchopulmonary dysplasia or significant cardiac disease.

💡Reactive Airway Disease

Reactive airway disease, also known as asthma, is a chronic condition where the airways become inflamed and narrow in response to various triggers. The video notes that a long-term complication of bronchiolitis is the development of reactive airway disease, with a higher risk among patients who had severe bronchiolitis, those younger than six months, and those with a family history of atopy.

Highlights

Bronchiolitis is one of the most common winter illnesses in children and a leading cause of frustration for pediatricians and parents.

It is characterized by initial upper respiratory symptoms that progress to a lower respiratory inflammatory process.

Respiratory syncytial virus (RSV) is the most common cause of bronchiolitis, seen in 80% of patients.

Clinical features of bronchiolitis are the same regardless of the causative virus.

Bronchiolitis is the top reason for hospitalization among infants and young children in the USA.

The physiological changes in bronchiolitis include airway edema, increased mucus production, and epithelial cell necrosis.

A classic pattern of bronchiolitis includes an upper respiratory prodrome followed by lower respiratory symptoms peaking around days three to five.

Bronchiolitis primarily affects children under two years of age, with those under six months at higher risk for severe illness.

Risk factors for severe bronchiolitis include age under 12 weeks, prematurity, chronic lung disease, congenital heart disease, daycare attendance, school-aged siblings, secondhand smoke exposure, and lack of breastfeeding.

Physical exam findings in bronchiolitis include fever, cough, trouble breathing, and signs of respiratory distress.

Bronchiolitis is a clinical diagnosis; lab work and imaging are not routinely indicated except in severe or complicated cases.

Treatment for bronchiolitis is primarily supportive care, with no routine use of medications like bronchodilators or antibiotics.

Hospitalization for bronchiolitis is indicated by severe dehydration, respiratory distress, apnea, lethargy, and low oxygen saturation.

Prevention strategies include smoking cessation, hand hygiene, breastfeeding, and RSV immunoprophylaxis for high-risk infants.

Complications of bronchiolitis can include aspiration pneumonia, respiratory failure, and the development of reactive airway disease or asthma.

AAP guidelines emphasize evidence-based treatment to avoid unnecessary interventions and therapies.

Transcripts

hey this is sketchy we're all Learning

Company and this podcast is a review of

the material meant to be used in tandem

with our videos quizzes and symbol

Explorer to help the lessons stick

or use this to passively review a topic

while you're on the go

check out the link in the episode bio to

watch the video that goes with this

podcast

alright let's get started

[Music]

in this sketch we'll focus on one of the

most common winter illnesses in kids

broncholitis

[Laughter]

it's also one of the most frustrating

illnesses for pediatricians and parents

alike so stay tuned to find out why

for this sketch we'll Venture into a

wintry Forest of never before seen

snow-covered bronchial trees except

something strange about this Forest

it appears to be occupied by some

ghostly campers but these specters don't

seem that spooky in fact

they appear downright friendly so pop

into your up and atom machines and let's

Dive In

bronchiolitis depicted by the inflamed

red fruits on the tips of the bronchial

trees is a viral process characterized

by initial upper respiratory symptoms

such as rhinorrhea and nasal congestion

that progresses to a prominent lower

respiratory inflammatory process

the most common cause of bronchiolitis

seen in 80 of patients is respiratory

syncytial virus or RSV

Gasper the Friendly Ghost the mascot of

this ghost Camp is chilling next to an

RSV Tombstone to help remind you of this

other possible viral causes of

bronchiolitis include rhinovirus para

influenza cumulent metanumovirus

influenza adenovirus and Coronavirus the

regular one we're not talking covid here

the clinical features of bronchiolitis

are the same regardless of the causative

virus but RSV and co-infection with

multiple viruses tends to cause more

severe disease

bronchiolitis is the number one reason

for hospitalization among infants and

young children in the USA which is why

the number one on this Tombstone is the

only number that hasn't faded away

so what happens physiologically to the

Airways in bronchiolitis the viral

infection leads to lower respiratory

Airway edema represented by these

icicles dripping fluid off the bronchial

tree branches increased mucous

production depicted by this sticky

accumulation of sap and eventually

sloughing and necrosis of epithelial

cells within the airway denoted by the

sloughing bark breaking off of the tree

just looking at this picture of goopy

drippy shedding bronchioles makes me

want to get bronchiolitis

um

never

all of these changes lead to obstruction

of the lower airway kind of like how

this chubby squirrel is now obstructing

this hole in the tree someone ate a few

too many nuts today

there's a classic pattern to the disease

course of bronchiolitis and knowing this

pattern will help as you assess a

patient's clinical status there's an

initial prodrome of pretty standard

upper respiratory symptoms for example

rhinorrhea and nasal congestion which is

Then followed by the onset of lower

respiratory symptoms which includes

cough trouble breathing and wheezing and

or crackles two to three days later

these lower respiratory symptoms

generally peak in severity around days

three to five we'll talk a lot more

about the details in just a second when

we review the history and physical exam

you might hear pediatricians refer to

the winter as bronchiolitis season

because at least in the northern

hemisphere it affects patients primarily

in the fall and winter that's why the

Gasper ghost Camp is held in the dead of

winter I prefer a nice warm summer camp

but that's just me so who tends to get

bronchiolitis bronchiolitis usually

affects children two years of age and

younger represented by the two candles

on Gasper's birthday cake or I guess

it's his

death Day cake

the ghosts even eat cake

or eat at all

Egon I have questions for you

kids under six months of age and

especially those under three months of

age are at risk for more severe illness

you can see this depicted by this rough

looking corporeal cake which only has

half a candle I guess ghosts don't like

real cakes noted so how do kids with

bronchiolitis typically present they

will come in with a cough represented by

this puff of air coming from Gasper as

well as a fever which is seen in about

50 percent of cases and is depicted by

gaspar's flaming head

getting a good history is also important

as patients will often have had an upper

respiratory prodrome usually consisting

of a runny or stuffy nose and pictured

here by the ghost mom blowing her nasty

or shall we say ghastly nose boogers

gives a new meaning to the term

Boogeyman doesn't it

uh where was I these nasal symptoms

typically last for a couple days

followed by the onset of cough and

trouble breathing looks like the ghost

dad is coming down with something too

infants less than two months of age may

present with apnea alone and no other

bronchiolitis symptoms shown here by

this apnic ghost baby

parents may also report that their child

is making fewer wet diapers than usual

this trickling sap from the bronchial

tree and this puddle of yellow snow

should help remind you of this

this can be a sign of dehydration

related to insensible losses from their

increased respiratory effort and or from

decreased po intake secondary to nasal

congestion or reduced energy represented

by this falling slice of cake

when I'm sick I certainly don't want to

eat much either but I have to be pretty

darn sick to pass up chocolate cake

[Music]

when taking your history be sure to ask

about risk factors that can increase the

chance of more severe disease

an age Under 12 weeks and a history of

prematurity can both put an infant at

risk for more severe disease you can see

this represented by these three Moon

eggs one Moon covers the span of one

month remember and this tiny owl that

has hatched prematurely

in the case of premature infants this

increased bronchiolitis risk is because

they have a greater chance of having

underlying laryngo or tracheal Malaysia

or a floppy Airway and may have missed

the maternal transfer of some protective

antibodies in utero

other risk factors for severe

bronchiolitis include chronic lung

disease or bronchopulmonary dysplasia

represented by these wilty lung shaped

leaves hemodynamically significant

congenital heart disease depicted by

this Jagged crossed out heart carving on

the tree daycare attendance symbolized

by this little gathering of ghost kids

around the campfire having school-aged

siblings oh look Little Ghost twins

secondhand smoke exposure at home see

the smoke coming from the fire and a

lack of breastfeeding in early infancy

hence this formula bottle

the next clue to a diagnosis of

bronchiolitis is your physical exam pay

careful attention to the lung exam as

that will usually really cinch the

diagnosis don't forget to check and

review vital signs for all of these kids

in addition to a fever persistent or

transient oxygen desaturations may also

be present you can see this represented

by this living boy who with the help of

his glowing red ghost detector ring has

stumbled onto the ghost Camp you may

also see tachycardia which is depicted

by his elevated heart watch

next up after Vital Signs be sure to

check the overall appearance and mental

status of these kids altered mental

status manifesting is lethargy increased

sleepiness or decreased interaction with

others may be a sign of more severe

illness and is represented here by our

ghost detecting kid who is scratching

his head in confusion

I'd be a little perplexed myself if I

stumbled on a group of ghosts sitting

around a campfire let alone one drinking

from a baby bottle unless

next you'll want to check for signs of

dehydration depicted here by this

falling water bottle signs of

dehydration can include dry mucous

membranes a sunken fontanelle in infants

and or delayed capillary refill and poor

skin turgor

next up is your lung exam before jumping

to auscultation check for signs of

respiratory distress these include nasal

flaring which is a reflection of

increased Airway resistance grunting

which is the body's clever way to create

auto peep or positive end expiratory

pressure to help keep the Airways open

accessory muscle use like belly

breathing retractions which may be

subcostal intercostal and or

supraclavicular and tachypnea you can

see these signs represented by our

living kid who is huffing and puffing so

much after his encounter with the

ghostly campers that he has stretch

marks on his jacket okay okay now you

can listen on lung all sculptation you

may hear rails or fine crackles which if

you remember sound a bit like opening

velcro kind of like the straps on our

ghost hunting kids shoes

you may also hear expiratory wheezing

which reflects lower airway obstruction

wheezes often sound similar to a whistle

which is why we've depicted them here

with an actual whistle around our ghost

Hunter's neck

be sure to check for air movement as

well since a child with severely

obstructed Airways may not demonstrate

much wheezing if they are moving little

air

and these kids it can sometimes be

difficult to distinguish transmitted

upper Airway noises from their

rhinorrhea and nasal congestion from

lower airway noises

a helpful tip is to put your stethoscope

in front of your patient's mouth and

nose then compare those sounds to what

you hear on your lung exam transmitted

upper Airway sounds will be the same in

both places whereas lower airway noises

should only be present when auscultating

the lungs

bronchiolitis is a clinical diagnosis

lab work is not routinely indicated

especially for your run-of-the-mill case

in the outpatient setting viral panels

can be considered for hospitalized

patients or For Those whom the viral

panel result might change clinical

management note that we're not talking

about the workup of fever in a neonate

here that's a horse of a different color

and outside the scope of the sketch

Imaging is also not routinely indicated

in bronchiolitis the American Academy of

Pediatrics AAP policy is to avoid

Imaging in routine bronchiolitis

patients since the hyperinflation

scattered atelectasis and infiltrates

commonly seen do not correlate well with

clinical disease severity and finding

them can lead to the administration of

unnecessary antibiotics but

if your patient's presentation is severe

enough for an ICU admission or if

there's concern for a possible

complication like

secondary bacterial pneumonia then for

sure you can go ahead and order that

chest x-ray

chest x-rays and patients with

bronchiolitis typically reveal

peri-bronchial coughing represented by

this hand warmer wrapped around this

tree branch hyperinflation depicted by

these over-inflated balloons and or

atelectasis represented by these

shriveled collapsed balloons

with a consistent history in supporting

physical exam findings you're just about

ready to diagnose your patient with

bronchiolitis

but it's always a good idea to run

through a differential quickly to ensure

you're not missing something common

differentials for bronchiolitis include

viral triggered asthma exacerbation

bacterial pneumonia pertussis and

foreign body aspiration

head on over to the differential

diagnosis menu to learn more

now that you feel unconfident about the

clinical presentation and diagnosis of

bronchiolitis let's jump into management

so you know how to best take care of

these kids

the good news is that for the most part

bronchiolitis is a self-limited

infection there's a surprising

variability in the clinical management

of bronchiolitis despite updated

evidence-based AAP clinical practice

guidelines

pursuing interventions and therapies

that aren't recommended has been

associated with an increased length of

Hospital stay and no change in

readmission rate so keep those AAP

guidelines handy as you head onto the

wards and into Peds clinics and remember

that evidence-based treatment is the way

to go

the very first step in your management

plan is to evaluate the severity of your

patient's illness

during your history and physical exam

pay careful attention to hydration

respiratory status and oxygenation to

determine whether hospitalization

represented by the Red Cross on this

Tombstone is indicated or if your

patient is safe to stay at home

indications for hospitalization include

dehydration respiratory distress apnea

lethargy a toxic appearance and an

oxygen saturation less than 90 to 95

percent on room air keep in mind that

you'll want to reassess these kids a few

times before making a decision as the

clinical exam can change over time

the most important takeaway from this

lesson today is that the Mainstay of

treatment for bronchiolitis whether

hospitalized or at home is supportive

care

kind of like the supports on this

treehouse for the majority of previously

healthy infants with bronchiolitis

there's no indication for the use of

medications as part of your management

plan

take note of this treehouse sign to

remind you no meds allowed there's no

reason to routinely give bronchodilators

racemic epinephrine inhaled or oral

glucocorticoids leukotriene Inhibitors

or antibiotics to patients with

bronchiolitis none of these treatments

have been shown to have benefit they are

all associated with increased costs and

could result in adverse effects

similarly chest physiotherapy also

called chest PT is not recommended for

patients with bronchiolitis as there's a

no proven benefit and it could result in

your patient becoming more agitated and

distressed for hospitalized patients

with more severe disease there are a few

other options you can think about but

for the most part these kids just need

time and support of care too

all patients with bronchiolitis should

be placed on contact precautions

including gowns gloves and a mask like

these ones you see hung up in the tree

house to help prevent the spread of

viral infection

nasal suction often provided in

combination with saline nasal drops is

commonly used to help relieve nasal

obstruction and can be pretty helpful

it's depicted here by this ghostly Dust

Buster in the tree house

I wonder if the Ethereal HEPA filter is

good at getting ectoplasmic goo

just no there's not enough evidence for

a formal recommendation one way or

another on its use and make sure to

avoid deep suctioning as it can actually

be harmful

you can also try nebulized hypertonic

saline in the inpatient setting but it

should not be used in the emergency

department setting

monitoring oxygenation status is

important for patients with

bronchiolitis it's generally recommended

that for stable patients intermittent

oxygen saturation checks should be

performed rather than continuous

monitoring to avoid the unnecessary use

of supplemental oxygen you can see this

represented by this ghost's glowing red

human detector ring of course if your

patient has severe respiratory distress

or is admitted to the ICU then that's a

different story and you'll need more

thorough monitoring if your patient's

oxygen saturation dips below 90 then the

use of supplemental oxygen depicted by

this giant green O2 tank is indicated

and can be administered via typical

nasal cannula high flow nasal cannula or

even CPAP if they need a higher level of

support

intubation may be necessary in severe

cases with impending respiratory failure

which is usually manifested by severe

retractions poor or no air entry

lethargy fatigue and decreased

responsiveness

patients with bronchiolitis are at an

increased risk for dehydration so you'll

need to monitor their eyes and O's

closely

small frequent feeds are recommended in

stable patients if their respiratory

status allows

initiation of NG feeds represented by

this nose picker or IV fluids

represented by the fluid bag like icicle

hanging from the ivy vine and dripping

water may be necessary if respiratory

distress limits their po intake puts

them at risk of aspiration if they are

vomiting or their urine output has

dropped off

all patients with bronchiolitis whether

at home or hospitalized will also need

frequent monitoring with continual

reassessment for the need to escalate or

de-escalate care

for hospitalized kids most pediatric

hospitals have bronchiolitis treatment

Pathways based on AAP guidelines that

can be super helpful

in addition to the treatment options

we've talked about it's important to

address prevention and risk reduction

strategies too smoking cessation good

hand hygiene of the wash sink in the

treehouse and breastfeeding like this

opossum mama is doing should all be

encouraged since these can help reduce

the severity of symptoms and the spread

of infection

RSV immunoprophylaxis with palavizumab

also called synergist represented by

this super pale high-risk ghost sitting

next to an antibody shaped tree branch

is recommended for only a small subset

of high-risk patients under one year of

age including preemies born at less than

29 weeks gestation and infants with

bronchopulmonary dysplasia or

hemodynamically significant cardiac

disease

guidelines and eligibility criteria for

palavizzumab change yearly so be sure to

check each winter this is a highly

expensive medication but it does help

reduce the risk of hospitalization for

RSV infection in these kiddos

for many patients the bronchiolitis

clinical course is relatively

uncomplicated

but you still need to know about

potential short and long-term

complications to watch out for so let's

quickly review them

remember that infants with severe

disease and especially those with

underlying conditions are at a higher

risk for complications

as we mentioned earlier patients with

bronchiolitis are at risk for aspiration

pneumonia due to their tachypnea and

increased work of breathing check out

these two ghosts in the corner they're

super freaked out by the sight of a real

human in their woods so much so that

one's vomited all over the lung shirt of

his buddy infants who are struggling

with significantly increased worker

breathing generally need to be made NPO

and provided with enteral or IV

hydration to minimize the risk of

aspiration

patients with severe bronchiolitis May

progress to respiratory failure and

require intubation and mechanical

ventilation represented by this

laryngoscope flashlight

huh you'd think a ghost wouldn't have

trouble seeing in the dark

you know what they say about assuming

from a long-term standpoint the most

common complication of bronchiolitis is

the development of reactive airway

disease recurrent wheezing or asthma

note the inhaler in this ghost's mouth

the fear of seeing a human has

apparently spun his asthma out of

control

this asthma risk seems to be higher

among patients that had severe

bronchiolitis those younger than six

months and of course among patients with

a family history of atopy so be sure to

let caregivers know that the child might

wheeze with future illnesses and remind

them to talk to their pediatrician if

this does occur

so there you have it you're now the

master of one of the most common

infectious diseases you'll see in

Pediatrics especially during cold and

flu season seeing really is believing

once you've seen your first case of

bronchiolitis you'll never forget the

sound of those classic lung findings so

before the not so friendly ghostly Trio

shows up let's take one last look at

what we've learned

bronchiolitis is a self-limited viral

illness affecting the lower airway in

kids generally under age two it is the

most common reason for hospitalization

in infants and young children in the USA

and is especially common in the winter

months bronchiolitis is most commonly

caused by respiratory syncytial virus or

RSV for short but can be caused by other

viruses such as rhinovirus influenza and

para influenza virus coronavirus and

more

bronchiolitis classically presents with

one to two days of fever and upper

respiratory symptoms such as nasal

congestion and rhinorrhea followed by

worsening of symptoms around days three

through five with development of lower

respiratory symptoms like cough and

trouble breathing the pathophysiology of

bronchiolitis involves viral-induced

Airway edema increased mucus production

and necrosis and sloughing of Airway

epithelial cells leading to lower airway

obstruction the physical exam in

patients with bronchiolitis generally

demonstrates signs of increased work of

breathing such as tachypnea retractions

accessory muscle use grunting and nasal

flaring as well as abnormal lung sounds

like wheezes and crackles luckily most

kids with bronchiolitis do okay it is

generally a self-limiting viral illness

granted a frustrating and scary one for

pediatricians and parents alike that is

treated with supportive care

some kids are at risk for more severe

disease risk factors include age Under

12 weeks a history of prematurity

chronic lung disease significant cardiac

disease as well as other social factors

such as daycare attendants school-aged

siblings limited breastfeeding during

infancy and second-hand smoke exposure

RSV prophylaxis is recommended to help

prevent bronchiolitis in a small subset

of high risk infants those under one

year of age with a history of

prematurity less than 29 weeks

bronchopulmonary dysplasia or

hemodynamically significant congenital

heart disease

bronchiolitis is a clinical diagnosis

labs and imaging studies are not

indicated in your run-of-the-mill

bronchiolitis case but can be considered

in special circumstances like severe

illness or an unusual illness course

treatment of bronchiolitis involves

knowing what not to do as much as it is

knowing what to do AAP recommendations

include avoiding bronchodilators

antibiotics glucocorticoids racemic

epinephrine chest PT and deep suctioning

these do not improve treatment outcomes

and can in fact cause more complications

the Mainstay of treatment for

bronchiolitis in an outpatient setting

includes nasal saline drops and suction

small frequent feeds and monitoring

respiratory status and hydration as well

as other standard supportive care

measures

infants with severe bronchiolitis need

to be hospitalized for escalation of

care indications for hospitalization

include dehydration significant

increased work of breathing especially

if you are concerned about respiratory

fatigue or apnea poor oxygenation and

lethargy

patients who are hospitalized for

bronchiolitis may need hydration via

enteric or intravenous fluids frequent

suctioning as well as oxygen support

respiratory support generally starts

with nasal cannula and advances to high

flow nasal cannula CPAP or even

intubation if needed in severe cases of

respiratory failure nebulized hypertonic

saline is also sometimes tried luckily

the vast majority of kids with

bronchiolitis even those who need

hospitalization do well in the short

term complications of bronchiolitis

include aspiration pneumonia and

respiratory failure those children with

severe disease especially if under six

months of age and those with other

comorbidities are at higher risk for

developing recurrent wheezing or asthma

in the future

and that's it folks our time today is

just about up hopefully our ghost

hunting friend has enough instant

primordial soup mix to go around or at

the very least is pretty talented at

helping ghosts take care of their

unfinished business

oh geez uh Here Comes one now gotta go

see you next time

check out our other topics on YouTube or

go to sketchu.com for our full Suite of

MCAT and med school lessons thanks for

listening and stay sketchy out there